Provider Demographics
NPI:1588649248
Name:HANNA, NICOLE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HANNA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28248 N TATUM BLVD
Mailing Address - Street 2:BUILDING B1 SUITE 605
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-6343
Mailing Address - Country:US
Mailing Address - Phone:602-996-5595
Mailing Address - Fax:602-996-5607
Practice Address - Street 1:28248 N TATUM BLVD
Practice Address - Street 2:BUILDING B1 SUITE 605
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-6343
Practice Address - Country:US
Practice Address - Phone:602-996-5595
Practice Address - Fax:602-996-5607
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN099001163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ702002Medicaid
AZ702002Medicaid
AZZ85362Medicare ID - Type Unspecified